French version:

www.bienvenue-leogane.blogspot.com

This blog is written chronologically from top to  bottom.

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January 12, 2010

On January 12, 2010, an earthquake of magnitude 7 hits Haiti. The epicenter is located southwest of Port-au-Prince, and the diameter of its destruction stretches over 250 km, including Port-au-Prince and neighboring towns, like Leogane, the closest city to the epicentre of the earthquake...

Haiti in numbers (UNICEF, IHSI):

The poorest country in the western hemisphere, Haiti has suffered from poverty and oppression of corrupted governments for a very long time.

Population: about 9,000,000

Unemployment Rate: 65% of the active population

Poverty: 80% of Haitians live with less than 1$/day

Illiteracy: 47% of the population

AIDS: HIV prevails in 2.2% of the population

Life Expectancy at birth: 58 years old

The earthquake’s aftermath (MSF/DWB, AAOS):

About 250,000 casualties

About 275,000 people were wounded

3,000 – 5,000 estimated amputations

About 2,000,000 people lost their homes

About 50% of Port-au-Prince was destroyed

About 80% of Leogane was destroyed

Chaos and destruction

According to the ones who were there, the first few days that followed the earthquake were horrendous. Dead bodies were lined up in the streets so their loved ones could identify them before they were buried in communal graves. Everyone had to hurry because the bodies were decomposing rapidly and the odor was already becoming hard to bear. Several weeks after the catastrophe, bodies were still found underneath the ruins of the city, and some areas of Port-au-Prince were stained with the smell of trash and putrefaction. There was no water, no drainage, no electricity in most of the areas of Port-au-Prince and adjacent towns.

About 80% of Leogane had been destroyed, and its habitants had to wait several days before seeing the arrival of the first rescue teams...

January 12 - February 8, 2010

Soon after the earthquake, the medias started reporting enormous death tolls. Images and reports from Haiti were harsh, but one could sense that we were only shown the tip of the iceberg.

Médecins Sans Frontières (MSF/DWB) was already present in Haiti before the earthquake happened. Several MSF members were killed when the Trinité hospital in Port-au-Prince crumbled to the ground. That hospital had been managed by MSF for many years.

In the light of the magnitude of that catastrophe, and knowing that my training in orthopaedic and trauma surgery would be helpful, I volunteered to join MSF’s ranks just a few days after the quake. Medical help, especially surgeons, were greatly needed. It was an urgent mission that normally wouldn’t last more than 2-3 weeks depending on the availability of the surgeons, but also because of the conditions on site.

The victims mostly suffered from musculoskeletal lesions and open wounds. Surgeons, especially orthopaedics, would play an important part in helping the Haitian population.

For two weeks, I’ve waited to find out if I would go. I tried to stay up-to-date with the evolution of the situation over there through the media, various non governmental organizations (NGO), governmental agencies and also the first medical groups that joined the disaster relief like the AAOS (American Academy of Orthopaedic Surgeons).

In the evening of February 5, I’ve received a phone call from the headquarters of MSF-Switzerland asking me if I could be ready to leave on the morning of February 8. I said yes without any hesitation. On February 6, I spent part of the day organizing my absence. I had to cancel or reschedule my pending surgeries, organize my rounds and clinics and find replacement colleagues for my on-call days...

Since I am a staff surgeon in a University Hospital, my humanitarian undertaking caused a few problems, not only on an organizational level, but also on a personal one, as the hospital’s management didn’t entirely agree with my decision to leave.

On Sunday February 7, the Saints won the Superbowl against the Colts. I was leaving for Haiti three hours after the game...

February 8 - 9, 2010

The Saints won their first Superbowl against the Colts, 31-17, a superb game.... I was leaving on the morning of the 8^th on a flight from Geneva to Madrid, then Madrid to Santo Domingo on that same day.

Once in the Dominican Republic, my luggage was nowhere to be found. After filling forms at the lost luggage counter, I was driven to a hotel where a meeting was set up for the next day at Santo Domingo’s MSF headquarters (HQ) for a briefing about our trip to Haiti. MSF members who were back from the front lines conducted the meeting. Standard safety measures were learned and a dozen of volunteers headed towards Santo Domingo’s airfield for a flight to Port-au-Prince where we would be dispatched to our respective final destinations.

I traveled with the MSF logs (logisticians) and administrators. The tension amongst the group was more and more palpable as we were waiting for our flight. The airfield is a transit base usually used by journalists and active NGOs in Haiti.

After a 2-hour wait filled with the same feeling as if we were going to war, we finally boarded our one-hour flight to Port-au-Prince.

February 9, 2010

Port-au-Prince :

We’ve arrived at Port-au-Prince international airport, which was managed by American military and still not accessible to long carriers at the time. As we were descending towards our destination in the 10-seater bi-propeller plane that took us there from Santo Domingo, the pilot said: "Welcome to Haiti, here it's survival of the fittest, good luck in your mission..." The tone was set. The atmosphere was one of a country at war with military helicopters (mostly Americans) taking off and landing on an overheated tarmac in a continuous ballet.

Formalities to enter Haiti were brief for NGO’s and journalists. Three vehicles were waiting to take us to our respective HQ (MSF-Switzerland, MSF-France, MSF-Belgium). The atmosphere was chaotic in town, the areas we drove through were partially destroyed, and numerous vehicles were lined up in traffic jams. The heat, the omnipresence of the military, the surrounding desolation and chaos all contributed to a very particular atmosphere, heavy and filled with adrenaline. However, the desire to jump right in was irresistible, and every single one of us was anxious to start his/her mission...

The MSF-Switzerland HQ is located in the higher parts of Port-au-Prince in the middle of a residential area that was somewhat spared by the earthquake. It's a 3-story house with a terrace on the roof, which offers a breathtaking view of the whole city. The inside courtyard serves as a parking lot for about fifteen MSF vehicles. The main lobby is equipped with radio and communication devices, charts of arrivals and departures, map of the city, etc... The first floor is a central station where all the volunteers bump into each other in an organized chaos. Every single square inch is used, and I see about 20 computer stations set up for all the different resources used by MSF.

After introducing myself with my traveling companions (the others had been directed to other national HQs of MSF), we were told about the destinations of our missions. My companions will stay in Port-au-Prince, while I was assigned to the Sainte Croix hospital in Leogane...

During my bumpy ride here, I became aware of the way things work with MSF. It’s an unusual NGO, one that uses local resources and has the will to break the rules to make things move faster. There’s little inertia in MSF’s functionality. It reacts in urgent situation and evolves in terrains where other organizations waste time evaluating situations that require immediate actions, as needed here in Haiti.

MSF-Switzerland manages several hospitals in Haiti: Lycée (a hospital established in a old high school), Mickey in Port-au-Prince, and Sainte Croix Hospital in Leogane, to name a few... Other hospitals like Cité-Soleil or Saint Louis are managed by MSF-France and MSF-Belgium. Every national MSF HQ manages its own infrastructures and teams.

LEOGANE:

During the two hours that took us to drive the 30 kilometers between Port-au-Prince and Leogane, I got to realize the magnitude of the catastrophe. Entire blocks of the city were destroyed, and the road was lined up with debris and refugees without shelter. The odor and shadow of Death were oppressive. I arrived in a field hospital set up in the middle of a destroyed schoolyard in Leogane. The entrance was guarded and there was a sign on the front gate with MSF’s initials. About 10 big tents constituted the hospitalization units, surrounded by 10 others that served as lodging for the volunteers in the camp. Part of the school building was still standing and served as a stock room for supplies, and also held the surgical ward.

This facility could hold about 100 hospitalized patients. The outpatient department (OPD)  handled over 150 consultations daily. There was about 35 volunteers and 50 Haitian employees (drivers, nurses, etc...). This place also managed the distribution of food and tents to the population, as well as the set up for water and sanitation in neighboring areas.

The medical unit was made of 2 surgeons (1 orthopaedist and 1 abdominal/general surgeon), and 7 first aid doctors (urgent care specialists and one pediatrician). The medical team was made of about 15 nurses and one physical therapist. The amenities allowed us to perform urgent orthopeadic care procedures such as casts, external fixators, as well as tractions. There was no x-ray unit or radiology. The sanitary conditions didn’t allow internal fixations (plates, screws, nails, etc...).

The majority of injuries caused by the earthquake affected the musculoskeletal system: open wounds, fractures, etc... Diseases like Dengue Fever, Malaria, diarrhea and other chronic pathologies were also handled in Leogane. The hospital had a maternity ward, with an average of one birth per day.

I arrived there with only my backpack, as my luggage was still lost somewhere between Geneva and Santo Domingo... The camp’s administrator, Pierluigi, as well as the medical manager, Nadia, wished me welcome and introduced me to the rest of the team. There was Benjamin, the general/abdominal surgeon from Switzerland, and Manoli, a physical therapist from Greece, who were both very happy to see the arrival of an orthopaedic surgeon. I picked a tent next to Benjamin as my quarters, and after a brief visit of the facilities, Pierluigi started to brief me on my mission and the local situation. During our conversation, another 10-second aftershock shook the ground and knocked down a couple of walls from the ruins of school... Pierluigi shook my hand and told me “welcome to Leogane”...

February 10, 2010

First real workday at Leogane  Hospital. The night before, we did our daily round of hospitalized patients, and several cases were elected for surgical intervention for the next day. There were several skin grafts and one open amputation (lower thigh), the latter was needed to prevent the infection of a previous below knee ampuation.

A few procedures were added to our day’s schedule, including an urgent C-section for a pre-eclampsia indication that gave birth to a set of twins, we also performed numerous wound debridements and about a dozen conservative fracture treatments. Almost all injuries were open wounds or fractures dating from the earthquake. Some injuries were already been taken care of in urgency, but sometimes in an inappropriate manner, which resulted in the need for secondary treatment or even surgery.

The day in the OR started around 8:00 am and usually ended between 6:00 and 7:00 pm. We made our round of hopsitalized patients around 7:00 pm, and after having solved the daily issues, we planned the procedures scheduled for the next day. Our day ended with dinner in the company of all the other residents in the camp around 8:00–10:00 pm. Nighttime gatherings were privileged moments, because they not only gave us a chance to unwind and relax, but they also gave us the opportunity to organize the following day and spend some time exchanging our stories of the day with the ones that spent it outside of the hospital (mobile clinics, distribution teams, expeditions and teams giving help to the population on the field).

 

We had about 10 vehicles. We were under a tight surveillance when we needed to leave the hospital, because there were risks for us to be mugged, kidnapped...

It’s easy to assess the workload and conditions under which we had to work. Even though we had all the supplies needed for basic surgery, we were missing simple things like cast’s saws, power tools for external fixators, staplers for skin grafts, etc... There were no x-ray unit, and the only facility available with one was located at a 10-minute car ride in the Canadian military hospital just outside Leogane.

We treated about 30 cases per day in our surgical ward. The simplest cases (debridements, casts, tractions and wound dressing changes) were performed on exam tables in the middle of the ward. The more complex cases, in need of a "sterile" environment, were handled inside the OR, separated from the surgical ward by a tarp and equipped with a surgical table and basic anesthetic supplies. Most anesthesia were induced by epidural or use of Ketamin for most of our "general anesthesia".

 

The simple organization of the surgical ward allowed two surgeons to go from one table to another to perform our respective procedures. Five Haitian nurses and two MSF OT scrub-nurses assisted us. Extra helpers were in charge of bringing the patients to the OR and cleaning the tables after each procedure.

This first day has set the tone for my mission, and I realized that it will be difficult, frustrating at times, but undeniably gratifying...

February 11 - 16, 2010

This first week has allowed me to accustom myself with the surrounding atmosphere. Days are loaded with work and usually begin with a wake up call at 6:30 am followed by breakfast with the rest of the team. Breakfast comes with a side of Doxycyclin as Malaria is endemic in this region.

We then prepared for the patients that had been elected for surgeries during the previous day's round. The OR was operational starting at 8:00 am, and these patients and the ones admitted during the day set the rythm of our day.

We perform about 30 procedures per day, of which about 5-10 are in the "closed" OR. Most of the cases were wound treatments, fractures with conservative treatments (casts), external fixators or even tractions. We perform skin grafts on a daily basis, procedures for which a protocol was established by Benjamin and that we followed systematically. We also routinely perform standard surgeries, abscess drainage, C-sections, etc...

The day in the OR ended around 7:00 pm with a short break to rest a little. We did rounds of the hospitalized patients every day.  During those rounds, which included the nurses, physical therapists and other practitioners (anesthesiologists, internists, etc...), we determined the treatment’s course of action as well as the surgical plans for each patients to be followed the next day. Each patient had a file in which we wrote the surgical follow-up and treatment plan with adjustments of medications. I was in charge of the treatment plan for patients with fractures, 20 of which had fractures of the femur (our Traction Ward). I had to decide who needed x-rays based on my clinical evaluation, who would benefit from walking rehabilitation and when, for how long and with what weight bearing. I also had to determine the surgical course of action for orthopaedic patients needing skin grafts, in collaboration with Benjamin. I’ve also created an Excel list to facilitate the categorization of all patients and their treatment plans. A list that will not only be useful for the nurses, but also be of assistance to my successors, so they will be able to follow all treatment plans already in course, and adjust them if needed.

Our daily rounds, and our workday in general, ended often between 9 :00 and 10 :00 pm with dinner, sometimes we had Haitian rhum, music or a debriefing from various MSF representatives.

Interactions with other residents and workers of the camp was very worthwhile. We exchanged our stories of the day, our past experiences and projects for the future.

Aside from having the opportunity to meet a population wounded by this natural and humanitarian disaster, I’ve also had the privilege of meeting extraordinary people. Amongst them were administrators, physical therapists, nurses and doctors. All of them came from different backgrounds and social classes, but all had one common interest: devotion towards the one in need. All of which came without any religious duty or cliché desire to be a "savior of humanity". I have great respect and admiration for those that I have met, and this blog is dedicated to them...

Melting pot of cases

The last two weeks had been abundant in experiences. I’ve seen more cases in the last two weeks than I have seen in a year working in an "occidental" hospital. Wounds were numerous, some infected, others infested with maggots, among other surprises...

Desperate cases were numerous, and the frustration caused by them is even more bitter as being in charge of these kind of cases is part of my daily agenda in Switzerland. Fractures that would require standard surgeries and protocol in any trauma center cannot receive the same treatment here in Haiti, where surgeries are limited by inadequate infrastructures...

I remember this man who came to our urgent care center with a wound on his right eye lid. Despite a rapid course of antibiotic treatment, the wound became quickly infected, so we suspected a case of Anthrax... We were forced to intubate the patient urgently because of respiratory problems. His face was so swollen that the intubation was performed in extremis. He managed to survive, but lost his eye...

Amongst many other cases, I remember taking care of a man in his 40s with a complex fracture of the proximal femur. His lower limb was shortened in external rotation. He was seeing by a doctor for the first time three weeks after the earthquake. I reduced the fracture and placed the limb in an 90° elevated traction.

Many children had come to our infrastructure, a great deal of them with wounds, as the one of this 6-year old boy who came to us with a scalp wound on his head. Closing that wound required several interventions including rotational flaps performed by a plastic surgeon that happened to be passing by.

A small 9-year old girl came to us with symptoms of osteomyelitis of her femur. Her case interested so many of us that a different diagnosis was set (we had x-rays done for her): sarcoma. We proceeded with a bone biopsy and sent the sample to the USA for analysis. The results were reassuring as the osteomyelitis was the correct diagnosis, we were then able to treat the wound with a course of antibiotics.

Three types of antibiotics were available: Cephalosporin, Penicillin and Ciproxin.

The daily grind comes with its load of unexpected situations. There are still everyday trauma that need to be taken care of: victims of motorcycle accidents, people that have fallen off of trucks or have been ran over. We also have a few cases of Appendicitis, Tetanus, Malaria, Dengue fever, etc...

February 17 - 24, 2010

Every day comes with its share of surprises, good or bad, but a lot gets accomplished. We’ve been able to organize the transfer of about 15 patients with fractures to obtain x-rays. Those transfers required meticulous organization, as the only facility equipped with a radiology unit was at a Canadian military hospital located at a 10-minute car ride. We have to carefully prepare our patients with tractions on their fractured limbs. Our physical therapist Manoli or myself were designated to accompany these patients. Once there, x-rays were taken and saved on a CD, it allowed us to make better decisions when it comes to the course of treatment of each of these patients.

My colleagues in the Canadian army have also asked for my professional opinion on some of their patients. Even with the light competition going on between the NGOs present on the field, interactions amongst colleagues are filled with mutual respect. After all, we’re all working towards the same goal: to help the victims. The interactions with surgeons from other NGOs, most of them Americans, are numerous and constructive. These surgeons often put their knowledge at our disposition and even their supplies whenever we need them. We gladly do the same in return. Therefore, we’ve been able to recruit plastic surgeons, hand specialists, and even pediatric-orthopaedics. I would like to take this opportunity to thank these colleagues: Craig, Christina, Phil, Tim, Anthony and all the others....

Benjamin couldn’t believe it. We’ve managed to organize a multidisciplinary grand round to discuss a few of our more difficult cases with our American colleagues. For a moment there, our small field hospital looked like a university center. It was a memorable event and a useful one too, as we were able to take important decisions, notably in organizing the transfer of patients needing internal fracture fixations. Ambitious plans to create such an infrastructure at the MSF St Louis hospital in Port-au-Prince was in the making at the time, and that facility was already overwhelmed with demands....

The supplies at our disposition in Leogane were sufficient for the basic treatments we provided. However, they were highly insufficient in supporting what was often expected of us. We were severely lacking an infrastructure that would have allowed us to perform internal fixations with plates/screws or nails.

The interventions performed during the first few days that followed the earthquake had often had failed. These failures have been the result of poorly performed procedures due to the inadequate infrastructures. Sadly, many of these procedures have resulted in complications, notably infections needing a lot of extra surgical attention to be fixed. Unfortunately, that extra attention couldn’t allways be provided in Haiti, again because of the inadequate infrastructures in the country.

We’ve treated hundreds of cases, often in an appropriate manner, sometimes desperately, but always with the conviction that we were doing the best that we could for our patients.

February 24 - 26, 2010

Time goes by quickly under these conditions. I’ve been in Leogane for about two weeks now, and time has come for me to leave. An orthopaedic surgeon arrived on the 24th to take over my duties. The list of patients and their treatment plans was up-to-date, and the transition has gone smoothly with one last round scheduled with my patients right before my departure. It’s very emotional for me to leave my patients behind because we have built close relationships based on blinded trust. Saying goodbye was difficult... I won’t get the satisfaction of seeing the Traction Ward patients walk again. My successor probably will...

We have been able to organize a few interventions for pastients who needed internal fixations. As for myself, my departure was scheduled for the afternoon. There’s a two-hour drive to the HQ of MSF-Switzerland in Port-au-Prince, and from there we waited for our flight to Santo Domingo before going back to Europe. I’ve taken advantage of those two days in Port-au-Prince to visit the local MSF infrastructures. I was able to meet with several of my counterparts in various hospitals of the city: Lycée, Cité-Soleil and Mickey. It’s been rewarding to discuss our shared experiences and impressions of the situation.

A hefty earthquake that waked up the entire household marked my last night in Port-au-Prince... After that, few of us were able to go back to sleep. I experienced two aftershocks while I was in Leogane, but we were inside tents that didn’t risk to fall down on us. In Port-au-Prince, each aftershock was felt more dramatically in buildings that still were a threat to their occupants.

The following afternoon, an MSF flight took me to Santo Domingo where I spent another night in a hotel with nothing planned other than resting and debriefing. I finally reached the old continent on the 26th of February...

Epilogue

I’m often asked if this mission was a good experience... to which I answer that it was an unexpected experience, a slap in the face...

Essentially, what first motivated me to go on that mission was my wish to put my abilities to good use and help those in need. I didn’t want to find myself looking back one day thinking, “I could have done something...”

As it turns out, the reasons that motivated me to go on that humanitarian mission and still motivate me to go on others are differentiated. When you choose to become a surgeon, you must understand that surgery is a peculiar world. It’s not all about scalpels and surgeries. One must be prepared to live a life made of decision making, responsibilities, lavished with fierce competition, glory, frustration and adrenaline... In a situation like the one in Haiti, circumstances push you to return to the basics: patients. There’s no more competition, or glory, or even conventions and congresses. There’s only the relationship between a doctor and a patient, the quintessence of our vocation.

Back in a modern hospital, I appreciate the return to the other aspects of my career, those mentioned above. However, my experience in Haiti has reminded me why I chose the career that I have, and what the bearings of my work are.

I would go back on a mission tomorrow if I could...